Calder, Michael James

Contributing factors

• Excessive opiate dosing in opiate-naive patient
• Combination of slow-release and short-acting opiates with overlapping peak effects
• Gabapentin adding to sedative burden
• Unrecognized obstructive sleep apnoea
• Failure to recognize oxygen desaturations as sign of deterioration
• Failure to escalate at critical oxygen saturation threshold of 90%
• Aspiration pneumonia secondary to impaired airway protection
• Poor communication between physician and nursing staff
• Inadequate documentation of treatment rationale
• Inadequate supervision and escalation by nursing staff
• Critical observations not recorded or acted upon
• Incomplete handover of sleep apnoea history to treating team
• Patient in closed room without continuous monitoring

Coroner's recommendations

1. Strengthen two-way communication between visiting medical officers and nursing staff beyond the improvements already implemented
2. Implementation of Adult Deterioration Escalation Chart (ADEC) to replace MEWS
3. Mandatory use of continuous pulse oximetry for patients on patient-controlled analgesia and those with respiratory risk factors
4. Clear escalation processes and mandatory escalation at oxygen saturation thresholds
5. Bedside handovers with documented communication of respiratory risks and sleep apnoea status
6. Mandatory competency and performance reviews for permanent night staff
7. Enrollment of permanent night staff in day shifts minimum 4 weeks per year for professional development
8. Use of SHARED handover template with explicit flagging of respiratory risks
9. Ward educator presence for 8 shifts per fortnight
10. Pain management to be explicitly addressed in all clinical handovers
11. Clear guidelines on oxygen therapy and its indication
12. Completion of patient history forms including sleep apnoea screening
13. Review of ED observation recording processes to ensure continuity with ward assessment